INTEGRATED CLINICAL PATHWAY

BUDI SAMPURNA

SISTEMATIKA

PENGERTIANTUJUAN DAN MANFAATPENGEMBANGANKEUNTUNGAN, PERHATIAN, DAN KENDALACONTOH

PENGERTIAN

Many synonyms exist for the term Clinical Pathways including:

Integrated Care Pathways, Multidisciplinary pathways of care, Pathways of Care, Care Maps, Collaborative Care Pathways

AIMS:

Facilitate introduction of guidelines and systematic and continuing audit into clinical practice Improve multidisciplinary communication and care planning, including with primary care Reach or exceed existing quality standards Decrease unwanted practice variation Improve clinician-patient communication and patient satisfaction Identify research and development questions

Harry Campbell, 1998

PENGERTIAN

An integrated care pathway (ICP) is a multidisciplinary outline of anticipated care, placed in an appropriate timeframe, to help a patient with a specific condition or set of symptoms move progressively through a clinical experience to positive outcomes.Variations from the pathway may occur as clinical freedom is exercised to meet the needs of the individual patient.

Bandolier

ICPs are important because they help to reduce unnecessary variations in patient care and outcomes. They support the development of care partnerships and empower patients and their carers.ICPs can also be used as a tool to incorporate local and national guidelines into everyday practice, manage clinical risk and meet the requirements of clinical governance.When designing and introducing ICPs, it is important to incorporate them into organisational strategy and choose appropriate topics which will provide opportunities for improvement.

Bandolier

Perspektif pasien:

“An Integrated Care Pathway is a timetable of events which will happen to you whilst you are in hospital. All your tests, medical treatment and nursing care are noted inside of this leaflet. The pathway is a guide, for you and your family.”

Perspektif dokter:

‘This ICP is intended as a guide to clinical care and the document on which to record the patient’s progress through an episode of care, but at any time clinicians/practitioners are free to exercise their own professional judgment.All deviations from this pathway (positive or negative) must be recorded as a Variance.’

ICP is dynamics

Developing ICPs is a very complex and time consuming phenomenon. It can be very difficult, considered, that given any particular set of symptoms, no patient is clinically identical, nor responds in the same way to a treatment. Besides the guidelines also have to be modified and adapted locally to suit the local choices (given that the adaptations are evidence based)

Sheenu Jhawar

Clinical Pathways were introduced in the early 1990s in the UK and the USA, and are being increasingly used throughout the developed world. Clinical Pathways are structured, multidisciplinary plans of care designed to support the implementation of clinical guidelines and protocols.

OPEN CLINICAL knowledge management for clinical care

They are designed to support clinical management, clinical and non-clinical resource management, clinical audit and also financial management. They provide detailed guidance for each stage in the management of a patient (treatments, interventions etc. ....) with a specific condition over a given time period, and include progress and outcomes details.

OPEN CLINICAL knowledge management for clinical care

Clinical Pathways have four main components (Hill, 1994, Hill 1998):

a timeline, the categories of care or activities and their interventions, intermediate and long term outcome criteria, and the variance record (to allow deviations to be documented and analysed).

OPEN CLINICAL knowledge management for clinical care

Pathways vs Guidelines, Protocols & Algorithms

Clinical Pathways differ from practice guidelines, protocols and algorithms as they are utilised by a multidisciplinary team and have a focus on the quality and co-ordination of care.

SYARAT

Kelompok pasien harus sesuai / cocok (suitable): mengikuti suatu perjalanan yang dapat diduga (follow the predictable course), ada pola episode penyakitnya

Pasien bedah: Pembedahan, dirawat beberapa hari, pulangPasien medis: mengikuti tahap2 penyembuhan tertentu, atau manajemen medisnya berubah pada titik-titik tertentu

Melbourne Royal Children’s Hospital

Clinical Pathway Development

Pilih topik

Select the area of practice. We chose the area with a selection matrix, including diagnoses, with higher costs, higher volumes, higher mortality, higher length of stay, or greater number of outcome variations.

Contoh Topik pada AHA(American Heart Association)

Memilih tindakan: bypass surgery, diagnostic catheterization, coronary angioplasty, acute myocardial infarction, and unstable angina Alasan:

high-volume dan high-costPredictable courseBanyak variasinyaBukti adanya noncompliance

Circulation. 2000;101:461

Tentukan Tim Kerja

Build the multidisciplinary work-team. We involved physicians (from family practitioners to specialists), nurses, therapists, social workers, and administrators providing care in the selected area.

Tim kerja

Inisiatif biasanya dari Perawat, tetapi keikutsertaan dokter harus ada, karena ini mempengaruhi kepatuhan terhadap pelaksanaan ICPIkut sertakan seluruh unit terkait, seperti house staff, physical therapy personnel, and dietary personnel

Pelajari Care Pathway

Define the diagnosis. We identified clinical selection criteria for each diagnosis with explicit and shared disease-staging scales. Define the patients. We identified other selection criteria as non-clinical, such as socio-economic factor, housing status, age of the patient, etc.

Pelajari kepustakaan pula

Review practice and literature. We analysed the care processes and researched the best evidence for the patients. The results of this phase came from all the members of the team.

Dari data pasien, temukan data pathway nya: gejala, perjalanan penyakitnya, tata-laksananya, variasinya dan alasannya, responsnyaDari kepustakaan, temukan best practice berdasarkan EBM. Bila tidak ada data, gunakan bench-mark

Develop the clinical path. We started by defining the appropriate goals to satisfy the multidimensional needs of the patients ( patient focus phase). Next we ‘translated’ the results from the review phase into elements of care detailed in local protocols and documentation, including the sequence of events and expected progress of the patients over time. The elements of care for each professional were defined according to the care categories

Penentuan format ICP kadang menjadi masalah.Makin kompleks-tampak komprehensif, tapi sukar dipatuhiSeringkali format checklist lebih mudah dipatuhiPenting: TASK-TIME MATRIX

Pilot and implement the clinical pathway. We educated the staff and monitored the use of the pathway. This last step was carried out by completing data record sheets that summarized the tasks of each professional during the care of the patients and the possible deviations from the path.

Ongoing evaluation. We assessed the level of completion of the data recording, investigated why there were any differences between the one in practice and the recommended one (deviations from the pathways), and measured patients’ outcomes.

Kunci Penting:Catat semua variasi / penyimpangan dari pathway, berikut alasannyaPelajari root-causenyaPelajari cara pencegahan / penangananPerbaiki guideline nya, sehingga semakin mendekati pathway

Implementation. The last phase consisted of the daily utilization of the clinical path, its regular monitoring (every 3 months) and updating (yearly).

How to use integrated care pathways

(1) Follow the integrated care pathway for every patient with the chosen condition. (2) Complete integrated care pathway documentation, signing for key elements of care provided as they are carried out. (3) Be free to deviate from the care specified in the integrated care pathway provided they justify the deviation and enter this in the variance sheet.

Harry Campbell, 1998

How to use integrated care pathways

(4) Take appropriate action when the integrated care pathway identifies patients whose progress is less good than expected or faster than expected. (5) Ensure that patients understand the care pathway as it relates to them, and allow them access to the integrated care pathway.

Harry Campbell, 1998

How to use integrated care pathways

Variance sheets should be inspected regularly to identify common reasons why the integrated care pathway was not followed. This should lead to discussion within the team and regular updating of the integrated care pathway when appropriate

Benefits, concerns, and barriers

Benefits of integrated care pathways

Facilitate the introduction of local protocols based on research evidence into clinical practice Result in more complete and accessible data collection for audit and encourage changes in practice Encourage multidisciplinary communication and care planning Reduce the size of case notes; less staff time spent on paperwork

Benefits of integrated care pathways

Promote more patient focused care and improve patient information by letting the patient see what is planned and what progress is expectedEnable new staff to learn quickly the key interventions for specific conditions and to appreciate likely variations Facilitate multidisciplinary audit and prompt incorporation of improvements in care into routine practice

Concerns about integrated care pathways

Investment of time which could be spent in other clinical activities May discourage appropriate clinical judgment being applied to individual cases Difficult to develop in circumstances where there are often multiple pathologies or where clinical management is very variable

Harry Campbell, 1998

Concerns about integrated care pathways

May stifle innovation and progress Need leadership, energy, good communication and time to be implemented successfully Have the potential to be misused if factional health care interests have undue influence; in particular, health management may misuse them to reduce patient care costs inappropriately

Barriers to implementationReluctance to change: this is understandable at times and should be anticipated Lack of suitable existing evidence based guidelines and inadequate time and resources to develop these locally. Obstructive interpersonal politics Lack of credit given for improvements in quality of care.

Harry Campbell, 1998

Barriers to implementationMany management supported initiatives have been cost driven. Many of the potential benefits of implementing integrated care pathways are quality based, though cost savings have been reported Attempting to change practice with partial information and no guidance or support. The person responsible for coordinating any care planning initiative must be sufficiently well informed and of high enough standing within the organisation

Contoh pada “Appendectomy”

Expected Outcome

CasemixCasemix information is used as a tool in both financial and clinical management of health services. The Australian Refined Diagnosis Related Groups (AR-DRG) is the Casemixclassification currently in use for acute inpatients. As further patient classification systems are developed and information systems are improved Casemix will continue to be used to help provide more effective and efficient health care across the spectrum of health settings